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Changes in hemostasis caused by different replacement fluids and outcome in therapeutic plasma exchange in pediatric
Volker Witt1, Herbert Pichler1, Elisabeth Beiglboeck1
1St. Anna Kinderspital, Department for Pediatrics, Medical University of Vienna (MUW) Kinderspitalgasse 6, 1090 Vienna, Austria.
Insights
Therapeutic plasma exchange (TPE) in children using solvent/detergent-treated plasma or a combination with albumin maintained hemostasis. Patient survival depended on organ dysfunction, not adverse events, with TPE being safe.
Area of Science:
- Pediatric Hematology
- Critical Care Medicine
- Transfusion Medicine
Background:
- Therapeutic plasma exchange (TPE) is increasingly used in pediatric patients.
- Limited data exists on TPE outcomes and optimal replacement fluids in children.
- Current recommendations for pediatric TPE replacement fluids are adapted from adult protocols.
Purpose of the Study:
- To evaluate the impact of different replacement fluids on hemostasis during TPE in pediatric patients.
- To assess patient outcomes, including survival rates and adverse events, associated with TPE in children.
- To provide evidence-based recommendations for TPE fluid selection in pediatric critical care.
Main Methods:
- Retrospective analysis of 324 TPE treatments in 35 pediatric patients (2008-2013).
- Categorization of TPE procedures based on replacement fluid: solvent/detergent-treated (S/D) plasma, 5% human albumin, or a combination.
- Assessment of hemostasis via INR, aPTT, fibrinogen, and ATIII levels; organ dysfunction using a modified MODS Index; and evaluation of outcomes and adverse events.
Main Results:
- Solvent/detergent-treated plasma alone or in combination with albumin maintained hemostasis within acceptable ranges.
- Human albumin alone significantly increased INR and aPTT, indicating potential hemostatic compromise.
- Patient survival was significantly associated with a lower Multi Organ Dysfunction Syndrome (MODS) Index (<2), with a low incidence of adverse events (1.2%).
Conclusions:
- Solvent/detergent-treated plasma, alone or combined with albumin, is effective in preserving hemostasis during TPE in pediatric patients.
- Caution is advised when using human albumin alone in critically ill children due to potential hemostatic alterations.
- Patient outcomes are strongly linked to the degree of organ dysfunction, underscoring the need for further controlled studies in pediatric TPE.
Background:
Therapeutic plasma exchange (TPE) is a generally accepted and frequently performed procedure for numerous therapeutic indications in adults. Slowly, TPE is also becoming more and more popular in the treatment of pediatric patients. Although, we know that TPE is safe in pediatric patients, the outcome of children treated with TPE is rarely reported. Furthermore, there are only general recommendations regarding the plasma replacement fluid for children and these are adopted from adults. Data concerning outcome and the influence of different types of replacement fluids on hemostasis in children are scarce.
Methods:
We retrospectively evaluated 324 TPE treatments performed in 35 patients between 2008 and 2013 in our level 4 institution for pediatric hematology and oncology. The plasmapheresis procedures were categorized into three groups based on the replacement fluid used. The first group received solvent/detergent-treated (S/D) plasma (70.0% of patients), the second group was administered 5% human albumin (7.7% of patients) and the third group was treated with a combination of human albumin 5% and S/D plasma (22.3% of patients). To assess hemostasis, data on INR, aPTT, fibrinogen and ATIII were collected before and after plasmapheresis from the patients' charts. A modified Multi Organ Dysfunction Syndrome (MODS) Index was used to classify organ failure. Patient outcome, survival rate and adverse events were evaluated.
Results:
We found a significant increase in the INR by 35.83% and of the aPTT by 18.53% within the human albumin group. The INR and aPTT of patients allocated to the S/D plasma group decreased by 1.58% and 15.77% on average, respectively. The combination group revealed a mild increase of the INR (9.47%), accompanied by a reduction of aPTT (5.97%). Furthermore we found that the survival rate was significantly associated with a MODS Index of <2 (p<0.001). Overall, the number of adverse events was low (1.2%) and none of these were considered life-threatening.
Conclusion:
Hemostasis could be preserved in a clinically acceptable range for a variety of underlying diseases with SD plasma alone or in combination with human albumin. Based on our results we would recommend practitioners to closely pre-estimate the hemostatic situation before using human albumin alone in critically ill pediatric patients with a limited ability to produce coagulation factors. The outcome of the patients in our collective exprience is correlated to the extent of organ dysfunction. Therefore further controlled studies are highly recommended.
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